Family Health Teams workers in Rio de Janeiro : leadership aspects in a study on organizational climate

Organizational climate is understood as the formal or informal perception of policies, practices, actions and organizational procedures, and is a factor of influence in the efficiency of the results, as well as in the conduct of people that are part of an organization. This paper describes one of organizational climate realms, namely, leadership, comparing the strata of professional categories of the Family Health Teams in the city of Rio de Janeiro. Thus, an administrative-based survey was carried out with a sample of n = 9,590 people in 187 primary healthcare units (71 Family Clinics and 116 Municipal Health Centers). The results show that all items that measure the realm of “leadership” were positively evaluated with differences between strata (p-value <0.001). We recommend conducting regular studies and holding leadership workshops in the very health units, as well as using distance-learning tools to exchange information and train staff.


Introduction
Organizational climate is understood as the formal or informal perception of policies, practices, actions and organizational procedures, and is a factor of influence in the efficiency of the results, as well as in the conduct of people who are part of an organization 1,2 .It should be noted that, in organizations with a favorable organizational climate, activities become more comfortable and easier, resulting in greater job satisfaction and increased potential for workers 3 .
Loch 4 quotes an article by Ducker and proposes eight practices for effective managers.Managers should: (i) ask what needs to be done; (ii) ask what is good for the institution; (iii) make plans of action; (iv) assume responsibility for the decision; (v) take responsibility for communication; (vi) focus on opportunities rather than problems; (vii) hold productive meetings; and (viii) say "we" instead of "I".
In its most usual definitions, the concept of leadership consists of three elements: influence, group and objective.Leaders try to influence, induce and affect the behavior of others, a process that occurs in a group context.The last element involves the idea of direction -the behavior of group members is influenced towards achieving certain goals.These elements were highlighted and applied in leadership theory and research, markedly until the mid-1980s.From then on, the definitions used the "symbolic management"concept.In the symbolic perspective, the fundamental characteristic of leadership would be to promote values that provide shared meanings about the nature of the organization 5 .Thus, leaders are those who "change the way people think about what is desirable, possible, and necessary".
With this in mind, we understand that the organization of work is the result of an intersubjective process, in which various subjects interact with a given reality, implying a dynamic of interactions proper to work situations, as a place of production of psychic meanings and building social relationships.Organizational climate studies are strategic management tools, since they allow internal and external analysis andmonitor employee satisfaction and commitment vis-à-vis the organization, ensuring, through strategies and actions, people growth and development and maximum productivity and quality, aiming at achieving and exceeding the results pre-set by central management.
In the health sector, the manager or director of a primary health care facility should be pre-pared to deal with unexpected events that may occur with users at the health establishment or at home, to relate to multiprofessional teams, to be aware of medical procedures and to mediate possible conflicts in inter-relational situations, that is, this professional has to exercise and develop leadership in relation to family health teams, transforming ideas, intentions and goals into results, harmonizing the work environment of the professionals, actively participating in the planning processes, knowing the guidelines of the SUS and the Family Health Strategy in order to meet the demands and needs of the population 6 .
In addition, managers need to be qualified, recognizing the tools most important to their work, enabling them to identify the potentialities and optimize teamwork, creating new leaders in order to exercise shared management, serving as an example of conduct for an efficient work that constantly improves its quality 7 .
Maffei 8 raises some questions in the work process of the Family Health teams: How can we combine institutional democratization with operational capacity and, therefore, with some level of vertical centralization, without which establishments would be lost in endless discussions or in particularisms?How can we provide independence and autonomy to each team, without losing the sense of network commitments, without losing the notion of system or without compromising the guideline of care comprehensiveness?How can we ensure a dialogue between users and professionals?How can we motivate professionals and how can we increase their capacity for reflection and self-esteem?How can we coordinate autonomy and creativity with professional responsibility?Thus, the execution of managerial activity requires the use of interdisciplinary tools, considering the technical capacity, but also the ability to articulate the political, economic and social relations in the work process and in the organization of health services.These professionals must act as leaders and be good listeners.They should know about planning, intervention strategies, agreement forms, work management, knowledge and people management, besides the organization of the network and issues related to maintenance and infrastructure of a health facility 7,9 .One of the ways to provide this type of training in Rio de Janeiro has been the Public Health Specialization Course of the National School of Public Health 10 .
In this context, many of the hardships in implementing actions and procedures foreseen in primary healthcare proposed by the Municipal Health Secretariat of Rio de Janeiro 11 are associated with organizational factors, such as difficulty in teamwork and the organization of the health establishment, which may influence the quality of services offered to users.On the other hand, some studies positively associate organizational climate and the competence of nursing professionals 12,13 .
In its third consecutive year of existence, the Organizational Climate Survey proposed and applied by the Municipal Health Secretariat in 2015 had aimed at, besides opening another official communication channel within the SMS, where all employees, without exception, enjoy freedom and confidentiality with regard to their participation, listening to the opinion of its employees and encouraging decision-making and exchanging experiences through its results.
This paper aims to describe one of the realms of the organizational climate, namely, leadership, comparing the professional category strata of Family Health Teams.

Material and methodology
We developed a cross-sectional administrative study, listing the universe of research from the National Register of Health Establishments (CNES), updated monthly by the Municipal Health Secretariat of Rio de Janeiro.
We noticed, during the planning of the study, that we had to collect e-mails from the entire base of the Subsecretariat of Primary Healthcare, Promotion and Health Surveillance.The first great movement to do so, and thus make efficient communication,was to bring teams of the OT-ICS-RIO 14 Network, which are spreadthroughout the Planning Areas of the Municipality, and thus produce a joint effort to gather email addresses of all the employees of the network.
In 2015, in its third year of consecutive application and already included in the annual calendar of regular management activities, research is conducted in eight realms: (i) communication; (ii) interpersonal relationship, (iii) relationship and recognition; (iv) leadership; (v) professional development; (vi) remuneration; (vii) satisfaction and (viii) management (Chart 1) and in most of the questions, the categories of answers followed options on a continuum in ordinal scale, which ranged from (1) never; (2) almost never; (3) almost always; and (4) always.Authors adapted this tool from the Great Place to Work methodology 15 .
We proposed the questions to all employees, without exception, and applied them in a non-mandatory and confidential way, that is, in a way that could identify nominally the respondent, only the stratum of his/her professional category.The overall response rate was 68.6% and the sample achieved n = 9,590 people in 187 primary care facilities (71 Family Clinics and 116 Municipal Health Centers) in the ten health planning areas of the city.There was high adherence of practically all professionals, except the health surveillance worker (HSW) (Table 1).We believe that this low HSWrate is associated with the difficult understanding of the importance of the survey, as well as the low expectation regarding the response to their desires in the work process.
The data required to develop the research were collected through a questionnaire with semi-open questions and the tool used was Sur-veyMonkey software, whose license for use was acquired for the study.Several academic institutions around the world have been using this device to collect their data because they are easily captured, stored and exported for analysis in other software or even internally from managerial reports generated by software with absolute and relative frequencies.
Survey was applied to health professionals for five days, from Monday to Friday.The decision to have a very limited application time considered: (i) producing the idea of urgency in respondents and (ii) inhibiting possible fraud in the responses, since the search link would be "open".Access to the questionnaire was made available through a link sent to all employees via e-mail and through a computer in the Community Workers' room.
For greater adherence in the responses, joint efforts to hold training exercises were carried out with so-called "engagement agents" in order to explain, exemplify and somehow identify possible changes and proposals for the application of the research.The selection of employees who would be trained and transformed into "engagement agents" considered the excellent performance of their work activities, proactivity and good relationship with the team, as well as the mandatory requirement of being a Community Health Worker (CHW).All were indicated by the management or director's office of the health facility.Altogether, 800 Community Health Workers were trained to assist in the application of the tool, in addition to submitting the most common issues to the coordination of the research, issues that could be the same as those of other management employees.Thus, training was efficient, generating demands It was necessary to use an online tool known as "word clouds" 16 to analyze qualitative data.This tool allows you to create an image of words from a given text.Words that occur more frequently in the text appear more prominently in the cloud.One can choose different fonts, word arrangement and color schemes to make them easier to see.The tool was chosen to read some specific questions.

Results
The five items that made up the question block (realm) of "leadership" were considered.In all of these questions, statistically significant differences were observed for the chi-square test (p-value < 0.001) when clustered responses "never / almost never", "always / almost always" and "does not know / did not answer" were compared.Between 70 and 80% of the answers about leadership were positive, that is, respondents stated that the presented question had "always / almost always" been realized.
As for the item in this unit we celebrate overcoming, results and achievements, most professionals agreed with this statement.Regarding question "I realize that my immediate supervisor is in line with the other supervisors.All of them convey the same message to their teams", we highlightthat in the "Nursing assistant/technician" and"management team (technicians and managers)" categories, there was a higher proportion of non-response, between 10 and 13%, the same occurring for the item "My manager / director keeps me informed about important day-to-day SMS issues.When questioned as to whether "my immediate leadership knows how to coordinate people and distribute tasks properly", the "always / almost always" results for community health workers (68.0%) and nursing assistants / technicians (70.6%) drew our attention.These were the lowest indices obtained, which suggests a greater overload of these professionals or lack of their understanding vis-à-vis their immediate supervisors in the FHS.Finally, the question "Do I get clear feedback on the progress of my work and my attitudes?"was well evaluated by workers in general.
An important finding relates to family physicians in the Family and Community Medicine Residency Program in the facilities.This research stratum obtained the best satisfaction indexes for the leadership characteristics surveyed, which refers to the interaction with their TR physician or facility management / direction.This means that the recent establishment of this Program (in 2012) and the insertion of these doctors into the establishments have been achieving satisfactory results of integration with the local administration (Table 2).
Regarding the findings of another research item, question 10 "who do you consider your immediate supervisor" (Table 3), this is associated with leadership ability.It was found that the identity of the "immediate supervisor" is not found in the most obvious and expected functions of the management, as in the case of doctors and family nurses (nurse -technical responsible nurse; doctor -technical responsible doctor), that is, professional categories recognize their supervisor in the facility, more so because of the leadership profile than by definition of the SMS, which makes him/her a supervisor, even without formally being appointed so.
When questioned about characteristics that would motivate professionals to work in the Family Health Strategy of the municipality, positive words such as "team", "help", "community", "population" and "work itself " (Figure 1).

Discussion
There is a conflict between the definition of the duties of professional community health workers and what they routinely perform at their facility, some of which are more overloaded with actions and services and do not manage to achieve their home visits' goals due to the poor distribution of their activities.This professional category is still fragile because of the poor knowledge and understanding of the Family Health Strategy by their immediate supervisors.The partial notion of the Strategy by those who lead them increases the gap between their tasks and daily particularities, hampering intercommunication of knowledge and possible team-based case resolutions.Thus, "listening ability" is part of this cycle of learning and updating processes adapted to the reality of each community and each team.Teams and their immediate supervisors need to bridge the basic rules predefined by the Ministry of Health and SMS and be flexible to adapt to a changing reality where rules that work within a municipality management may not necessarily work with another team.Deleuze 17 attests to this reality by asserting that individual subjection modes no longer operate by constraints or rigid rules (disciplinary societies), but by facultative self-internalized rules.This author argues that the individual is curiously led to identify with these rules, which are seen as necessary and even desirable, and with models that test and attest to the performance and level of adherence to the presuppositions of efficiency and continuous evaluation, as if we were living in an endless series of updates or software updates.
The training developed by the National School of Public Health / Fiocruz has been fundamental for the training of primary health care facilities managers, in particular, through its Public Health Specialization Course, one of the first to be created in the ENSP.Historically, the field of training in Public Health consists of a set of basic disciplines (Planning, Programming, Organization of Services, Epidemiology and Social Sciences) and complementary disciplines, such as Statistics, Health Economics 18 .
However, as some authors point out 10 , the complexity of the questions posed to the health system points to the limit of the disciplinary structure in the formative processes to explain reality, as well as new teaching-learning methodologies such asthe constructivist spiral and the learning communities 19 .
Permanent education emerges as an additional strategy to qualify the health care process, in order to guarantee comprehensiveness and effectiveness of PHC attributes in the daily practice 20 .Linking permanent education processes to the strategy of institutional support can greatly enhance the development of management skills and attention in basic care, as it increases the al-ternatives for coping with the difficulties experienced by workers in their daily lives 21 .

Final considerations
One of the limitations of this study was the low response rate of health surveillance workers.This can be explained by the fact that not all are included in the Family Health Teams and still work in an unintegrated way to the PHC work process.Future studies could be developed to further analyze this issue, as well as the application in other cities and the statistical validation of the tool would be highly desirable.
In this paper, we aimed to observe the development of work experiences that seek to exchange ideas and their results on the one hand, understand how the various categories of health professionals articulate and dialogue, and the visibility of the work process, its acts and perceptions, in order to try to demonstrate the level of democratization of decision-making processes.
Focus is, therefore, mainly on the team, on the small group where trust is developed andwhere the leader plays the role of its facilitator.In this viewpoint, we can understand this process from questions about the hardships in the progress of the so-called participatory management forms, and of partnerships between managers and workers, and later hold an important debate about leadership and the possibility of a mobilizing management.
The use of validated instruments for the periodic evaluation of the organizational climate in primary healthcare can contribute to understand the perception of workers in this area and help management in guiding actions and procedures necessary to achieve the established goals.
The realization of leadership workshops at the health facilities is also an important step for the organization of the work processes and alignment of goals proposed by the Municipal Health Secretariat of Rio de Janeiro.The use of distance education tools is also highly recommended to avoid the lack of professionals in the facilities, which is detrimental to the health care of the population.

Figure 1 .
Figure 1.Cloud of words of the question: "mention up to three characteristics of the Family Health Strategy that motivate you to continue working with us" -Municipal Health Secretariat -Rio de Janeiro.

Chart 1 .
Realms and items of the data collection tool.Do we celebrate overcoming, results and achievements in this facility?16.I realize that my immediate supervisor is in line with the other supervisors.Do they all convey the same message to their teams?17.Does my manager / director keep me informed about important day-to-day SMS issues?18.Does my immediate supervisor know how to coordinate people and distribute tasks appropriately?19.Do I get clear feedback on the progress of my work and my attitudes?
it continues not previously planned: (i) most professionals did not know the main abbreviations and acronyms of management; (ii) professionals did not know about jobs nomenclature, (iii) some profes-sionals were unsure as to the time and availability of response.Quantitative data were tabulated in simple and relative frequencies and, compared in each case, using the Pearson chi-square test.

Table 1 .
Would you like to work in another facility?35.Do you believe that your manager is transparent with the public funds he/she administers?(E.g.warehouse, office supplies, etc.) 36.I believe that public funds allocated by the municipality to the facilities are well managed.(E.g., drug logistics, campaign supplies and uniforms).37.I notice that my facility is concerned about the good management of public funds (turning off the lights at the end of the day, turning off the air conditioning, preventing waste of inputs and preserving assets).38.With regard to my facility's care capacity, I believe that it…?Obs: Questions 1 to 5 referred to sample characterization items and filters by occupational category stratum.Except for questions 9, 10, 25, 28, 29, 30, 31, 34 and 38, all others from the sixth one have ordinal scales with four points (never, almost never, almost always, always).Question 28, Net Promoter Score (NPS) is defined on a scale from zero to 10, with a score being assigned to the following question: "On a note from zero to 10, how much would you recommend your health facility for a selective process of a friend or acquaintance?"Distribution of the universe of the research and sample performed according to strata of professional categories in the primary healthcare facilities Municipality of Rio de Janeiro -2015.

Table 2 .
Distribution of the answers by items of the realm "leadership" according to occupational category of the Family Health Teams Municipal Health Secretariat of Rio de Janeiro -September / 2015.

get clear feedback on the progress of my work and my attitudes.
Note: Pearson's chi-square test was performed and p-values <0.001 were found in all questions in the Table.

Table 3 .
Distribution of the answers of the item "who do you consider your supervisor" according to occupational category of the Family Health Teams Municipal Health Secretariat of Rio de Janeiro -September / 2015.